MINUTES DICOM WORKING GROUP 15
MAMMOGRAPHY AND CAD
PLACE OF MEETING AMERICAN COLLEGE OF RADIOLOGY, RESTON, VA
DATE AND TIME MARCH 31, 2009: 10:00AM – 6:00PM
APRIL 1, 2009: 8:30AM – 3:00PM
MEMBERS PRESENT:
Fujifilm Medical Systems Paul Morgan
GE Healthcare Guillaume Peter (Wed AM phone)
Hologic, Inc. Janet Keyes
iCAD, Inc. Topher Gedeon
Northwestern Memorial (ACR) Judith Wolfman
Philips Medical Systems Bas Revet
Siemens Medical Solutions Renate Hoecker (Wed AM phone)
MEMBERS ABSENT:
*CareStream Health Zhimin Huo
*Medical College of Wisconsin (ACR) Charles Kahn
Planmed Oy Mari Varjonen
* = Does not count toward quorum.
OTHERS PRESENT:
American College of Radiology Staff Penny Butler
American College of Radiology Staff Laura Coombs (Tues PM)
American College of Radiology Staff Barbara Hirsch
Siemens Medical Solutions Kallol Chaudhuri (Tues PM phone)
PRESIDING OFFICER: Janet Keyes, Industry Co-chair
1. WELCOME AND REVIEW AGENDA
Janet Keyes called the meeting to order and provided an overview of the proposed agenda.
2. REVIEW OF PREVIOUS MINUTES
The meeting minutes for the September 23-24, 2008 meeting were approved as distributed.
3. REVIEW OF PREVIOUS ACTION ITEMS
Correction Proposals:
 Janet: Submit a letter ballot comment for CP-874 on behalf of WG 15 to define a
reference point coded term for mammography dose reporting. Completed.
 Bas, Janet: Request WG 6 to approve CP-910 and CP-911 for the October ballot
packet. Completed.
 Penny: Report results from the ACR committees regarding approval and/or
adjustment to the proposed view modifiers in CP-875. Completed.
 Janet: Update CP-875 based on feedback from the ACR committees, distribute to the
group, and request WG 6 to approve for the January 2009 voting packet. Completed.
Colon CAD SR:
 Topher: Finalize and present PC+3 of Supplement 126 to WG 6 in October, for letter
ballot approval. Completed.
 Topher: Finalize work on use of RadLex codes and SRT codes in Supplement 126.
Completed. DCM codes assigned while waiting for SRT codes.
Other:
 Janet: Notify the group when Supplement 125 final text is published. Completed.
 All: Continue to investigate breast tomosynthesis CAD needs, and report back at the
next meeting. In progress.
 Topher, Janet: Determine if clarification is needed in DICOM regarding the
representation of composite features in Mammography CAD SR. Completed.
 Janet: Send the WG 15 DICOM Strategy update to the DICOM Standards
Committee. Completed.
On Hold:
 Topher: Update the CAD SR finding description correction proposal.
 Janet: Complete initial draft of correction proposal to incorporate French translation
of new Breast Imaging Report terms from CP-527.
 Janet: Finish extracting the portions of Supplement 65, Chest CAD SR, revision 20
that were postponed, into a white paper as future work.
4. CORRECTION PROPOSALS
 CP-837: Add Filter Attributes to X-Ray Acquisition Dose and X-Ray Filtration
modules, Letter ballot comments were not completely incorporated into the Final
Text (October 2008). The two new attributes were not added to the Breast
Tomosynthesis Acquisition module as requested. Bas Revet requested an update to
the Final Text on behalf of WG 15.
 CP-857: Template format corrections to TID 40xx, Final Text October 2008.
 CP-874: Fixes for Radiation Dose Reporting, Final Text October 2008. Letter ballot
comments were incorporated into the Final Text, specifically the coded term (113865,
DCM, “Entrance exposure to a 4.2 cm breast thickness”) added to CID 10025
Radiation Dose Reference Points, which is used in TID 10003 Irradiation Event X-
Ray Data and TID 10004 Accumulated Projection X-Ray Dose.
 CP-875: Update CID 4014 and CID 4015, Letter Ballot completed March 16, waiting
for SNOMED codes for the new mammography view (ISO) and view modifiers (NP,
AC, IMF, AX) before Final Text. We expect these codes to be available summer
2009.
 CP-880: Add Breast Composition as numeric value in Dose SR, Final Text October
2008.
 CP-881: Add Reason For Performed Procedure Code Sequence, Final Text October
2008. Related to the IHE Mammography Acquisition Workflow profile.
 CP-886: Add codes describing procedure type and indication for Mammography
scheduling, Final Text October 2008. Related to the IHE Mammography Acquisition
Workflow profile. Note that IHE CP-155 incorporated DICOM CP-881, 885 and 886.
 CP-889: Stereotactic Information for Mammography, was split out from CP-875
again, based on e-mail discussion with WG 6, recommending not to use View
Modifier Code Sequence for these identifiers. Reverted to the alternate proposal from
the original CP-889, to use Image Type, Value 3. Assigned to March 2009 voting
packet, which WG 6 approved for Letter Ballot (CPack 51) at their March meeting.
 CP-904: Correct Mammo Terms to use “Marker” rather than “Clip”, went through
Letter Ballot in CPack 49 (January 2009), but was reassigned to WG 15 based on
ballot comments. The group worked through the ballot comments, added changes to
ensure that all “Marker” versus “Clip” discrepancies in PS 3.16 are resolved, and
created draft final text to be submitted to WG 6.
 CP-910: Add Tracking Identifier to TID 4004 and TID 4006, Final Text January
2009. Extension to Mammography CAD SR.
 CP-911: Add Condition to DX Patient Orientation, Final Text January 2009. Related
to specimen identification in Digital X-Ray and Digital Mammography X-Ray
images.
5. DIGITAL BREAST TOMOSYNTHESIS
Supplement 125 Final Text was approved by WG 6 on August 28, 2008, submitted for
publication on September 8, 2008, and published at the end of October 2008. Implementers
are in the process of examining the new IOD for incorporation into their products.
Bas Revet confirmed the approval of changes to attribute requirements in the Multi-frame
Dimension Module, proposed in the Letter Ballot of Supplement 43 Storage of 3D
Ultrasound Images (completed March 2009). This module is optional in the Breast
Tomosynthesis Image IOD. However, if it is utilized, the Dimension Organization Sequence
and Dimension Index Sequence are now required; changed from Type 2 to Type 1. This is an
alert to WG 15 members to watch for correction proposals that may impact modules and
macros that are now shared among all multi-frame image IODs (e.g. MR, CT, XA, XRF, X-
Ray 3D, Breast Tomosynthesis, US).
6. BI-RADS® ATLAS
Barbara Hirsch provided an update on plans for the fifth edition of the BI-RADS Atlas.
Strategy planning meetings were held in October and November 2008. One area of focus is
the improvement of example clinical images provided in the Atlas. The ACR is evaluating
the format to use for collecting images (e.g. TIFF, DICOM). Barbara has met with each of
the subcommittees (Mammography, Ultrasound, and MRI sections). At ECR in March 2009
the Mammography committee discussed international use of BI-RADS, specifically ensuring
the authenticity of local translations of BI-RADS. The Ultrasound committee will meet at
SBI in April 2009. The MRI committee met in February 2009 and will meet again at SBI.
Barbara and Penny will bring previous vendor feedback on the MRI section to the attention
of the MRI committee, specifically the spreadsheet prepared by Carol Moore (GE) in
August/September 2005. The target for reviewing changes to the Atlas is the first half of
2010. The target for publication is the second half of 2010. After the changes are approved,
WG 15 will pursue a correction proposal similar to CP-527 (August 2005), to update the
DICOM PS 3.16 Breast Imaging Report and Relevant Patient Information templates and
context groups as needed.
Laura Coombs visited the group on Tuesday afternoon to provide an update on progress of
the new ACR NMD. Vendors have started testing the new NMD in January 2009. Three
vendors have submitted test data, and screen shots from their applications that confirm the
mapping of application fields to NMD fields. At SBI the ACR will provide a demo of the
test NMD web site. At SIIM the ACR NMD will be part of a learning track, including a
demo and hands-on interaction with NMD reports, to assist participants to visualize the
benefits of participation. Target launch date is July 1, 2009.
7. COLON CAD SR
Topher Gedeon presented Supplement 126 to WG 6 for Letter Ballot approval in October
2008, which was completed via teleconference in January 2009. Supplement 126
successfully completed letter ballot in March 2009, with two sets of ballot comments
(Hologic, GE). Topher met with WG 6 in March 2009 to address the comments and prepare
draft final text. Topher presented the DFT+2 version of Supplement 126 to the group on
Tuesday, noting changes made since Letter Ballot, made updates based on the discussion,
and presented the DFT+3 version to the group on Wednesday. Topher will follow up with
WG 6 for approval and publication of the Final Text. Highlights of changes include:
 PS 3.6: UID assignments are needed for new context groups; introduced in CP-845
 PS 3.16 correction to TID 4128 Colon CAD Descriptors, row 4: DCID (300) should
be DTID (300)
 PS 3.16 change to parameters assigned in the inclusion of TID 300 in TID 4128;
removed $Equation and the associated coded term “Threshold method”
 PS 3.16 change to conditions in rows 9 & 10 of TID 300, reduced to “XOR” only
 PS 3.16 caution regarding use of “Rectal tube” as the code meaning for the SRT code
with preferred name “enema tube”
 PS 3.16 decision to go ahead with publishing DCM codes, then change them to SRT
codes via correction proposal upon availability
 PS 3.16 & 3.17: consistency of “Image Set Properties” throughout
 PS 3.17: updates to introductory text to clarify recording of detection versus analysis.
The Single Image Finding = Detection and Composite Feature = Analysis delineation
from Mammography and Chest CAD SR does not carry forward to Colon CAD SR.
 PS 3.17: updates to Examples 2 and 3 to replace the Single Image Findings with
Composite Features, since colon CAD systems work with image sets rather than
individual images.
Potential future extensions to Colon CAD SR include:
 Add colon preparation characteristics to the Colon CAD Findings Summary template.
 Add rendering guidelines for certainty of finding/feature, perhaps assigning colors to
groups of % values, as a characteristic of Rendering Intent.
 Add the vantage point (e.g. camera angle) from which to display a feature/finding,
perhaps as a characteristic of Rendering Intent.
8. OLD BUSINESS
DOT Mammography. This work item is on hold until another DOT Mammography
organization steps forward to take over editing Supplement 136.
Storage and exchange of CAD results for breast tomosynthesis. This item is tabled until
sufficient information is available to determine whether or not a new work item is required.
IHE Mammography. Group members reported on the 2009 North America Connectathon
held in February. Results are available at www.ihe.net. Vendors continued to test the IHE
Mammography Image profile. Unfortunately, there was not sufficient participation of
complementary actors (e.g. Order Filler, Acquisition Modality, Image Display, Image
Manager, Evidence Creator) to test the new Mammography Acquisition Workflow profile.
2009 Europe Connectathon is next, but may face similar challenges. The demonstration of
the Mammography Image and Mammography Acquisition Workflow profiles at SBI, April
26-29, 2009 in Colorado Springs was cancelled. Chris Carr of the RSNA is coordinating a
possible demonstration at SIIM, June 4-7, 2009 in Charlotte, NC.
IHE Radiology Reporting. The Radiology Reporting Committee will meet at RSNA
Headquarters (Oak Brook, IL) on May 19. Reporting system vendors are encouraged to
participate. Dr. Wolfman will discuss with Chris Carr regarding representation of the clinical
perspective on mammography reporting workflow. There is no news on the Mammography
Reporting Workflow proposal.
IHE Radiation Exposure Monitoring. This new profile is available for trial implementation in
2008-2009, and is being tested at the 2009 Connectathons (North America, Europe). It
makes use of the DICOM Radiation Dose SR, which is equipped for mammography dose
reporting.
Future view modifiers for mammography. There are still some alternate angle views that are
not specifically identified in the View Code Sequence / View Modifier Code Sequence of
Digital Mammography X-Ray images, for example, step-oblique MLO, or other variable
angle alternate views that are acquired to augment the initial screening or diagnostic views.
Such additional images will continue to pose a challenge for automated hanging protocols. If
the group can determine a general way to identify such images with additional view
modifiers, a new correction proposal will be created and submitted at a later time.
Composite Features in Mammography CAD SR. The group reviewed and accepted a new
correction proposal to clarify that no assumptions should be made regarding the multiplicity
or underlying structure within the Individual Impression/Recommendation containers. Now
that mammography CAD systems are expanding to include composite features, this is to alert
implementers and parsers that Individual Impression/Recommendation content may be
grouped, for example per image, per finding or composite feature, or some combination
thereof.
9. NEW BUSINESS
Clarify Breast Implant Present attribute description. The group reviewed and accepted a new
correction proposal to clarify when the value of Breast Implant Present is expected to be
YES. The group agreed that YES is expected whenever the imaged breast contains a breast
implant, even when a breast implant is displaced, or may not be visible in the pixel data.
ACR Information Technology Activities. Mike Tilkin, CIO of the ACR, visited with the
group during lunch on Tuesday. He described the coordination of all information technology
activities of the ACR under the IT Informatics Committee, which has five subcommittees.
The ACR DICOM and IHE committees participate in the Standards subcommittee.
10. NEW ACTION ITEMS
Correction Proposals:
 Bas, Janet: Follow up to ensure CP-837 final text is corrected.
 Bas, Janet: Follow up to ensure CP-875 moves to final text upon assignment of
SNOMED codes.
 Janet: Place the CP-904 draft final text in the WG 6 meeting folder for June, and send
a reminder to Bas Revet.
 Janet: Place the two new correction proposals in the WG 6 meeting folder for June.
Colon CAD SR:
 Topher, Bas: Obtain Context Group UIDs for Supplement 126 and add to the draft
final text.
 Topher: Place the revised Supplement 126 draft final text in the WG 6 folder, and
alert WG 6 to approve and publish the final text.
 Topher: Write a correction proposal upon assignment of SNOMED codes.
Other:
 Barbara: Update the group regarding progress on the BI-RADS Atlas fifth edition.
 Judy: Update the group regarding progress on IHE Radiology Reporting.
 Janet: Update the group regarding correction proposal progress, and any other topics
that may require scheduling of a WG 15 teleconference or face-to-face meeting.
11. NEXT MEETING
The next face-to-face meeting will be scheduled when the time comes to move forward with
a work item, such as CAD results for breast tomosynthesis, a multi-frame image IOD for
tomosynthesis projections, or DOT Mammography Image. Teleconferences may be
scheduled, as needed, to discuss maintenance topics (e.g. correction proposals).
12. ADJOURNMENT
The meeting was adjourned at 11:15am on April 1.
Reported by: Janet Keyes (co-Chair)
WG 15 of the DICOM Stds. Comte.
April 2, 2009
Reviewed by Counsel: April 15, 2009